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Cognitive Behavior Therapy and Metacognitive Therapy: Moderators of Treatment Outcomes for Children with Generalized Anxiety Disorder

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Abstract

Although cognitive behavioral therapy (CBT) is effective for childhood anxiety disorders, approximately 40% of youth remain anxious after treatment. Metacognitive therapy (MCT-c) for children with generalized anxiety disorder (GAD) has shown promising effects. The present study aimed to examine if CBT and MCT-c show differential effects in children with primary GAD based on baseline characteristics, in a quasi-experimental design. To investigate which treatment is most beneficial for whom, three potential moderators: age, symptom severity, and comorbid social anxiety were examined. Sixty-three children aged 7–14 completed CBT or MCT-c. Participants were assessed before and after treatment. Both CBT and MCT-c were highly effective in treatment of childhood GAD. None of the selected variables significantly moderated treatment outcomes. Subgroups of children with high symptom severity and social anxiety comorbidity showed trends of responding better to CBT. Methodologically stronger studies are needed to facilitate a better adaptation of treatment for children with GAD.

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References

  1. Reynolds S, Wilson C, Austin J, Hooper L (2012) Effects of psychotherapy for anxiety in children and adolescents: a meta-analytic review. Clin Psychol Rev 32:251–262

    Article  PubMed  Google Scholar 

  2. James AC, James G, Cowdrey FA, Soler A, Choke A (2015) Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev 2:1–105

    Google Scholar 

  3. Warwick H, Reardon T, Cooper P, Murayama K, Reynolds S, Wilson C, Creswell C (2017) Complete recovery from anxiety disorders following Cognitive Behavior Therapy in children and adolescents: a meta-analysis. Clin Psychol Rev 52:77–91

    Article  PubMed  Google Scholar 

  4. Gibby BA, Casline EP, Ginsburg GS (2017) Long-term outcomes of youth treated for an anxiety disorder: a critical review. Clin Child Fam Psychol Rev 20:201–225

    Article  PubMed  Google Scholar 

  5. Breinholst S, Esbjørn BH, Reinholdt-Dunne ML, Stallard P (2012) CBT for the treatment of child anxiety disorders: a review of why parental involvement has not enhanced outcomes. J Anxiety Disord 26:416–424

    Article  PubMed  Google Scholar 

  6. Wells A (1999) A metacognitive model and therapy for generalized anxiety disorder. Clin Psychol Psychother 6:86–95

    Article  Google Scholar 

  7. Wells A (2009) Metacognitive therapy for anxiety and depression. Guilford Press, London

    Google Scholar 

  8. Normann N, van Emmerik AA, Morina N (2014) The efficacy of metacognitive therapy for anxiety and depression: a meta-analytic review. Depress Anxiety 31:402–411

    Article  PubMed  Google Scholar 

  9. Esbjørn B, Normann N, Reinholdt-Dunne ML (2015) Adapting metacognitive therapy to children with generalised anxiety disorder: suggestions for a manual. J Contemp Psychother 35:159–166

    Article  Google Scholar 

  10. Simons M, Schneider S, Herpertz-Dahlmann B (2006) Metacognitive therapy versus exposure and response prevention for pediatric obsessive-compulsive disorder. Psychother Psychosom 75:257–264

    Article  PubMed  Google Scholar 

  11. Nordahl HM (2009) Effectiveness of brief metacognitive therapy versus cognitive-behavioral therapy in a general outpatient setting. Int J Cogn Ther 2:152–159

    Article  Google Scholar 

  12. Beck J (1995) Cognitive behavior therapy: basics and beyond. Guilford press, New York

    Google Scholar 

  13. Beesdo K, Knappe S, Pine DS (2009) Anxiety and anxiety disorders in children and adolescents: developmental issues and implications for DSM-V. Psychiatr Clin N Am 32:483–524

    Article  Google Scholar 

  14. Esbjørn BH, Normann N, Christiansen BM, Reinholdt-Dunne ML (2018) The efficacy of group metacognitive therapy for children (MCT-c) with generalized anxiety disorder: an open trial. J Anxiety Disord 53:16–21

    Article  PubMed  Google Scholar 

  15. Garcia AM, Sapyta JJ, Moore PS, Freeman JB, Franklin ME, March JS, Foa EB (2010) Predictors and moderators of treatment outcome in the pediatric obsessive compulsive treatment Study (POTS I). J Am Acad Child Adolesc Psychiatry 49:1024–1033

    Article  PubMed  PubMed Central  Google Scholar 

  16. Maric M, Prins PMJ, Ollendick TH (eds) (2015) Moderators and mediators of youth treatment outcomes. Oxford University Press, Oxford

    Google Scholar 

  17. Wolitzky-Taylor KB, Arch JJ, Rosenfield D, Craske MG (2012) Moderators and non-specific predictors of treatment outcome for anxiety disorders: a comparison of cognitive behavioral therapy to acceptance and commitment therapy. J Consult Clin Psychol 80:786–799

    Article  PubMed  Google Scholar 

  18. Ollendick TH, Jarrett MA, Grills-Taquechel AE, Hovey LD, Wolff J (2008) Comorbidity as a predictor and moderator of treatment outcome in youth with anxiety, affective, AD/HD, and oppositional/conduct disorders. Clin Psychol Rev 28:1447–1471

    Article  PubMed  Google Scholar 

  19. Walczak M, Ollendick T, Ryan S, Esbjørn BH (2017) Does comorbidity predict poorer treatment outcome in pediatric anxiety disorders? An updated 10-year review. Clin Psychol Rev 60:45–61

    Article  PubMed  Google Scholar 

  20. Hudson JL, Keers R, Roberts S, Coleman JRI, Breen G, Arendt K et al (2015) Clinical predictors of response to cognitive-behavioral therapy in pediatric anxiety disorders: the genes for treatment (GxT) study. J Am Acad Child Adolesc Psychiatry 54:454–463

    Article  PubMed  PubMed Central  Google Scholar 

  21. Lundkvist-Houndoumadi I, Hougaard E, Thastum M (2014) Pre-treatment child and family characteristics as predictors of outcome in cognitive behavioural therapy for youth anxiety disorders. Nord J Psychiatry 68:524–535

    Article  PubMed  Google Scholar 

  22. Nilsen TS, Eisenmann M, Kvernmo S (2013) Predictors and moderators of outcome in child and adolescent anxiety and depression: a systematic review of psychological treatment studies. Eur Child Adolesc Psychiatry 22:69–87

    Article  PubMed  Google Scholar 

  23. Barrett PM, Dadds MR, Rapee RM (1996) Family treatment of childhood anxiety. A controlled trial. J Consult Clin Psychol 64:333–342

    Article  PubMed  Google Scholar 

  24. Cobham VE, Dadds MR, Spence SH (1998) The role of parental anxiety in the treatment of childhood anxiety. J Consult Clin Psychol 66:893–904

    Article  PubMed  Google Scholar 

  25. Compton SN, Peris TS, Almirall D, Birmaher B, Sherrill J, Kendall PC et al (2014) Predictors and moderators of treatment response in childhood anxiety disorders: results from the CAMS trial. J Consult Clin Psychol 82:212–224

    Article  PubMed  PubMed Central  Google Scholar 

  26. Kerns CM, Read KL, Klugman J, Kendall PC (2013) Cognitive behavioral therapy for youth with social anxiety: differential short and long-term treatment outcomes. J Anxiety Disord 27:210–215

    Article  PubMed  Google Scholar 

  27. Gonzalez A, Peris TS, Vreeland A, Kiff CJ, Kendall PC, Compton SN et al (2015) Parental anxiety as a predictor of medication and CBT response for anxious youth. Child Psychiatry Hum Dev 46:84–93

    Article  PubMed  PubMed Central  Google Scholar 

  28. Taylor JH, Lebowitz ER, Jakubovski E, Coughlin CG, Silverman WK, Bloch MH (2018) Monotherapy insufficient in severe anxiety? Predictors and moderators in the child/adolescent anxiety multimodal study. J Clin Child Adolesc Psychol 47:228–266

    Google Scholar 

  29. Puleo CM, Kendall PC (2011) Anxiety disorders in typically developing youth: autism spectrum symptoms as a predictor of cognitive–behavioral treatment. J Autism Dev Disord 41:275–286

    Article  PubMed  Google Scholar 

  30. Barton S (2000) Which clinical studies provide the best evidence? [Editorial]. BMJ 321:255–256

    Article  PubMed  PubMed Central  Google Scholar 

  31. Rapee RM, Lyneham HJ, Schniering CA, Wuthrich V, Abbott MA, Hudson JL et al (2006) Cool Kids: Child & Adolescent Anxiety Program. Centre for Emotional Health

  32. Wechsler D (1991) Manual for the Wechsler intelligence scale for children-(WISC-III). Psychological Corporation, San Antonio

    Google Scholar 

  33. Silverman WK, Albano AM (1996) The anxiety disorders interview schedule for children (ADIS-C/P). Psychological Corporation, San Antonio

    Google Scholar 

  34. Silverman WK, Saavedra LM, Pina AA (2001) Test-retest reliability of anxiety symptoms and diagnoses with the Anxiety Disorders Interview Schedule for DSM-IV: child and parent versions. J Am Acad Child Adolesc Psychiatry 40:937–944

    Article  PubMed  Google Scholar 

  35. Chorpita BF, Yim LM, Moffitt C, Umemoto LA, Francis SE (2000) Assessment of symptoms of DSM-IV anxiety and depression in children: a revised child anxiety and depression scale. Behav Res a Ther 38:835–855

    Article  Google Scholar 

  36. Esbjørn BH, Sømhovd MJ, Turnstedt C, Reinholdt-Dunne ML (2012) Assessing the revised child anxiety and depression scale (RCADS) in a national sample of Danish youth aged 8–16 years. PLoS ONE 7:e37339

    Article  PubMed  PubMed Central  Google Scholar 

  37. Hayes AF (2017) Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. Guilford Publications, New York

    Google Scholar 

  38. Templeton GF (2011) A two-step approach for transforming continuous variables to normal: implications and recommendations for IS research. CAIS 28:41–58

    Article  Google Scholar 

  39. Pierce KA, Kirkpatrick DR (1992) Do men lie on fear surveys? Beh Res Ther 30:415–418

    Article  Google Scholar 

  40. Beidel DC, Turner SM, Morris TL (2000) Behavioral treatment of childhood social phobia. J Consult Clin Psychol 68:1072–1080

    Article  PubMed  Google Scholar 

  41. Mesa F, Le TA, Beidel DC (2015) Social skill-based treatment for social anxiety disorder in adolescents. In: Ranta K, La Greca AM, Garcia-Lopez LJ, Marttunen M (eds) Social anxiety and phobia in adolescents. Springer, Switzerland, pp 289–299

    Chapter  Google Scholar 

  42. Beidel DC, Alfano CA, Kofler MJ, Rao PA, Scharfstein L, Sarver NW (2014) The impact of social skills training for social anxiety disorder: a randomized controlled trial. J Anxiety Disord 28:908–918

    Article  PubMed  PubMed Central  Google Scholar 

  43. Chorpita BF, Yim LM, Donkervoet JC, Arensdorf A, Amundsen MJ, McGee C et al (2002) Toward large-scale implementation of empirically supported treatments for children: a review and observations by the Hawaii empirical basis to services task force. Clin Psychol Sci Pract 9:165–190

    Article  Google Scholar 

  44. Higa-McMillan CK, Francis SE, Rith-Najarian L, Chorpita BF (2016) Evidence base update: 50 years of research on treatment for child and adolescent anxiety. J Clin Child Adolesc Psychol 45:91–113

    Article  PubMed  Google Scholar 

  45. Normann N, Lønfeldt NN, Reinholdt-Dunne ML, Esbjørn BH (2016) Negative thoughts and metacognitions in anxious children following CBT. Cogn Ther Res 40:188–197

    Article  Google Scholar 

  46. Loerinc AG, Meuret AE, Twohig MP, Rosenfield D, Bluett EJ, Craske MG (2015) Response rates for CBT for anxiety disorders: need for standardized criteria. Clin Psychol Rev 42:72–82

    Article  Google Scholar 

  47. Kenny DR (2015) Moderator variables. Retrieved 13 November 2017 from http://davidakenny.net/cm/moderation.htm

  48. Smith KE, Hudson JL (2013) Metacognitive beliefs and processes in clinical anxiety in children. J Clin Child Adolesc Psychol 42:590–602

    Article  PubMed  Google Scholar 

  49. McClelland GH, Irwin JR, Disatnik D, Sivan L (2017) Multicollinearity is a red herring in the search for moderator variables: a guide to interpreting moderated multiple regression models and a critique of Iacobucci, Schneider, Popovich and Bakamitsos (2016). Behav Res 49:394–402

    Article  Google Scholar 

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Acknowledgements

The study was supported by grants to the Copenhagen Child Anxiety Project from the Tryg Foundation (Grant Number: 7-12-0702), Sygekassernes Helse Foundation (Grant Number: 2011A613), and Augustinus Foundation (Grant Number: 12-01-019). We would like to thank the foundations for supporting this study financially. We also wish to thank all participating children and parents for contributing to this study as well as all staff and psychology students who have assisted in the process.

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Authors and Affiliations

  1. Department of Psychology, University of Copenhagen, Øster Farimagsgade 2A, 1353, Copenhagen, Denmark

    Monika Walczak, Sonja Breinholst & Barbara Hoff Esbjørn

  2. Department of Psychology, Virginia Tech, Blacksburg, VA, USA

    Thomas Ollendick

Authors
  1. Monika Walczak
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  2. Sonja Breinholst
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  3. Thomas Ollendick
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  4. Barbara Hoff Esbjørn
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Correspondence to Monika Walczak.

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Conflict of interest

Monika Walczak, Sonja Breinholst, Thomas Ollendick, and Barbara Hoff Esbjørn declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by the Ethical Review Board at the Department of Psychology, University of Copenhagen.

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Walczak, M., Breinholst, S., Ollendick, T. et al. Cognitive Behavior Therapy and Metacognitive Therapy: Moderators of Treatment Outcomes for Children with Generalized Anxiety Disorder. Child Psychiatry Hum Dev 50, 449–458 (2019). https://doi.org/10.1007/s10578-018-0853-1

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